Proximal Coronary Artery Segments Research Articles

High-risk coronary plaque of sudden cardiac death victims: postmortem CT angiographic features and histopathologic findings.

High-risk coronary plaques (HRP) are characterized in clinical radiological imaging by the presence of low plaque attenuation, a napkin-ring sign (NRS), spotty calcifications (SC) and a positive remodeling index (RI). To evaluate if these signs are detectable in postmortem imaging by a multi-phase postmortem CT angiography (MPMCTA), a retrospective study of a series of autopsy well-documented coronary plaques related to sudden cardiac death (SCD) was performed. Then correlations between histological and radiological findings were described. Fourty SCD cases due to acute coronary syndrome based on clinical history and confirmed at autopsy were selected (28 men and 12 women, age 53.3 ± 10.9). The culprit lesion was mainly situated in the proximal segments of coronary arteries, in the right coronary artery in 23 cases (57.5%), the left anterior descending artery in 13 cases (32.5%), the circumflex artery in 3 cases (7.5%) and in one case in the left main stem. MPMCTA showed a positive RI (≥ 1.1) in 75% of cases with a mean RI 1.39 ± 0.71. RI values were lower in cases with fibrotic plaques. NRS was observed in 40% of cases, low attenuation plaque in 46.3%, and SC in 48.7% of cases. There were significant correlations of the radiological presence of NRS for fibrolipid composition of the plaque (p-value 0.007), severe intraplaque inflammation (p-value 0.017), severe adventitial inflammation (p-value 0.021) and an increased vasa vasorum (p-value 0.012). A significant correlation (p-value 0.002) was observed between the presence of SC at radiological examination and the presence of punctuate/fragmented calcification at histology. In addition, in 58.3% of cases, plaque enhancement was observed, which correlated with plaque inflammation and the fibrolipid composition of the plaque. The coronary artery calcium score was 314 (± 455). There was a poor agreement between stenosis of the lumen at histology versus radiology. Our study shows that the various radiological signs of HRP can be detected in all plaques by MPMCTA, but individually only to a variable extent; plaque enhancement appeared as a new sign of vulnerability. In the postmortem approach, these radiological markers of HRP, should always be applied in combination, which can be useful for developing a predictive model for diagnosing coronary SCD.

Longitudinal Stent Deformation at the Proximal Segment of the Left Main Coronary Artery Caused by a Stuck OCT Catheter: Case Report and Review of Literature

Longitudinal Stent Deformation at the Proximal Segment of the Left Main Coronary Artery Caused by a Stuck OCT Catheter: Case Report and Review of Literature

Deep Learning-Based Automated Labeling of Coronary Segments for Structured Reporting of Coronary Computed Tomography Angiography in Accordance With Society of Cardiovascular Computed Tomography Guidelines.

To evaluate a novel deep learning (DL)-based automated coronary labeling approach for structured reporting of coronary artery disease according to the guidelines of the Society of Cardiovascular Computed Tomography (CT) on coronary CT angiography (CCTA). A retrospective cohort of 104 patients (60.3 ± 10.7y, 61% males) who had undergone prospectively electrocardiogram-synchronized CCTA were included. Coronary centerlines were automatically extracted, labeled, and validated by 2 expert readers according to Society of Cardiovascular CT guidelines. The DL algorithm was trained on 706 radiologist-annotated cases for the task of automatically labeling coronary artery centerlines. The architecture leverages tree-structured long short-term memory recurrent neural networks to capture the full topological information of the coronary trees by using a two-step approach: a bottom-up encoding step, followed by a top-down decoding step. The first module encodes each sub-tree into fixed-sized vector representations. The decoding module then selectively attends to the aggregated global context to perform the local assignation of labels. To assess the performance of the software, percentage overlap was calculated between the labels of the algorithm and the expert readers. A total number of 1491 segments were identified. The artificial intelligence-based software approach yielded an average overlap of 94.4% compared with the expert readers' labels ranging from 87.1% for the posterior descending artery of the right coronary artery to 100% for the proximal segment of the right coronary artery. The average computational time was 0.5 seconds per case. The interreader overlap was 96.6%. The presented fully automated DL-based coronary artery labeling algorithm provides fast and precise labeling of the coronary artery segments bearing the potential to improve automated structured reporting for CCTA.

Positron emission tomography rubidium-82 myocardial perfusion imaging in diagnosing uncommon paediatric acute coronary syndrome: a case report

BackgroundAcute coronary syndrome (ACS) is uncommon among the paediatric population with no guideline in the management in this age group up to this date. This case report aims to introduce the Positron Emission Tomography Rubidium-82 (PET Rb-82 MPI) as one of the non-invasive diagnostic tools in paediatric acute coronary syndrome.Case presentationPatient is an 11-year-old boy with underlying Nephrotic syndrome who was referred to our hospital with the chief complaint of chest pain. This was associated with raised cardiac enzyme and S–T depression on the posterior leads of electrocardiogram. On his arrival, we noted raised lipid profile as well as proteinuria and hypoalbuminaemia. He had frequent relapse of Nephrotic syndrome with the latest episode was three months ago. He has a strong family history of ischaemic heart disease whom his father had an episode of myocardial infarction at the age of 40 as well as a strong family history of hypercholesterolaemia. His father and paternal uncle were diagnosed with hypercholesterolaemia at their early age. He was arranged for Coronary Computed Tomography Angiography which subsequently followed by PET Rb-82 MPI. The PET Rb-82 MPI demonstrated a large area of stress induced ischaemia in the left anterior descending, left circumflex and right coronary artery territories. The left ventricular size is normal with good systolic function and normal wall motion. Global coronary flow reserve was still preserved at 2.07. Following the multi-disciplinary meeting, diagnosis of ACS was established. Patient was treated with dual anti-platelets, and he was then arranged for coronary angiography. The coronary angiography showed complete occlusion of the left circumflex artery from the proximal segment. There was a mild disease at mid segment of the diagonal artery with myocardial bridging. There was also a moderate disease from proximal segment of the dominant right coronary artery. Paclitaxel drug coated balloons were inserted into the diagonal and left circumflex arteries.ConclusionsThis rare case report on paediatric ACS highlights the diagnostic value of PET Rb-82 MPI as one of the non-invasive imaging tools in diagnosing paediatric acute coronary syndrome.

Invasive Functional Assessment of Coronary Artery Disease in Patients with Severe Aortic Stenosis in the TAVI Era.

Coronary artery disease (CAD) is a common finding in patients suffering from aortic valve stenosis (AS), with a prevalence of over 50% in patients 70 years of age or older. Transcatheter aortic valve intervention (TAVI) is the standard treatment option for patients with severe AS and at least 75 years of age. Current guidelines recommend percutaneous coronary intervention (PCI) in patients planned for TAVI with stenoses of >70% in the proximal segments of non-left main coronary arteries and in >50% of left main stenoses. While the guidelines on myocardial revascularization clearly recommend functional assessment of coronary artery stenoses of less than 90% in the absence of non-invasive ischemia testing, a statement regarding invasive functional testing in AS patients with concomitant CAD is lacking in the recently published guideline on the management of valvular heart disease. This review aims to provide an overview of the hemodynamic background in AS patients, discusses and summarizes the current evidence of invasive functional testing in patients with severe AS, and gives a future perspective on the ongoing trials on that topic.

P305 MULTIVESSEL SUBACUTE STENT THROMBOSIS

Abstract The presence of comorbidities such as psychiatric pathologies negatively influences the prognosis of patients with acute cardiovascular events. A 62–year–old male patient suffering from arterial hypertension, dyslipidemia, ischemic heart disease, treated 3 years earlier with PCI of LAD, Cx e RCA (EF 45%), and schizophrenia, is hospitalized with a diagnosis of NSTEMI. Coronary angiography shows: eccentric stenosis 70% proximal to the pre–existing stent in the middle LAD; Intrastent occlusion of the middle circumflex branch with omocoronary rehabilitation and ulcerated critical plaque in the proximal segment of the right coronary artery with mild intrastent restenosis in the middle. The patient refuses cardiac surgery, so angioplasty with ultra–thin drug–eluting stents is performed. The patient starts DAPT with clopidogrel, choosing a combination formulation to promote compliance, with discharge on the fourth day. Three days after discharge, the patient returns with anterior STEMI, with multivessel intrastent thrombotic closure (LAD, Cx, RCA), so angioplasty with paclitaxel–releasing balloon is performed on LAD and with NC balloons on the right coronary artery; impossibility to obtain total recanalization of the circumflex branch due to the non–transit of guides, even hydrophilic and of different weights. During angioplasty and for the following 12 hours, bolus and infusion of tirofiban is administered due to the high thrombotic burden. The choice of the second antiplatelet agent in this second procedure fell on prasugrel. The patient is discharged on the sixth day and a long conversation is held with his wife regarding the correct management of the home therapy. One year later, the patient a dual–chamber ICD was implanted at another centre, with correct and regular assumption of home therapy. Our case demonstrates an infrequent form of multivessel thrombosis during STEMI. The presence of schizophrenia influences negatively the evolution of the natural history of ischemic cardiopaty. The psychiatric substrate exposes to a greater number of cardiovascular events, given the reduced therapeutic compliance, also as regards the choice of appropriate therapeutic strategies. A joint path between the hospital, local medicine and the family environment would be desirable in order to correctly manage this type of patient.

Treatment strategy for spontaneous coronary artery dissection based on anatomical characteristics

ObjectivesTo compare the clinical and angiographic characteristics of high-risk and low-risk spontaneous coronary artery dissection (SCAD) patients to determine the optimal treatment strategy.BackgroundSCAD is a rare and emerging cause of acute coronary syndrome and sudden cardiac death, especially in young female patients. However, the indication of percutaneous coronary intervention (PCI) in patients with SCAD remains elusive.MethodsWe evaluated the clinical and angiographic characteristics of all SCAD patients admitted to our center from 2012 to 2020. The outcomes of the high-risk and low-risk SCAD patients according to the location of the lesion segment with dissection or intramural hematoma were compared. Further analyses were performed to evaluate the vessel healing or residual dissection in the patients receiving the follow-up angiography.ResultsA total of 81 SCAD patients were enrolled in the present study, in which 38 patients were categorized as high-risk group, defined as involvement of the left main artery or proximal segment of any main coronary artery. PCI was the more common treatment approach in the high-risk group (68.4%), while conservative treatment was more common in the low-risk group (62.8%). The incidence of major adverse cardiac events, defined as cardiac death, myocardial infarction, unstable angina pectoris, severe arrhythmias, or heat failure, within 1 year follow-up was similar between the two groups. 57 patients (70.4%) received the follow-up angiography after 1 year. The high- and low-risk groups had a similar rate of vessel healing among the PCI treatment patients. However, more patients achieved spontaneous healing in the low-risk group than the high-risk group among the conservative treatment patients (86.4% vs. 33.3%, p < 0.05).ConclusionsConservative management remains the recommended treatment strategy for the low-risk SCAD patients. PCI could be considered in high-risk SCAD patients with favorable clinical outcomes and vessel healing. Characterization of lesion anatomy may be an important indicator for treatment decision.

Impact of percutaneous coronary intervention on critical proximal lesion of left anterior descending artery on left ventricular function by echocardiography and tissue doppler

Introduction: lesions in the proximal segment of the LAD coronary artery present a high-risk lesion, as this important anatomical location of atherosclerotic plaques is associated with increased mortality. Patients with chronic ischemic LV dysfunction but viable myocardium will have better LV geometry after revascularization, which in turn will enhance long-term outcome. Objective: to assess the impact of PCI on critical proximal lesion of LAD artery on LV functions by echocardiography and tissue doppler study. Materials and methods: We included 50 patients older than 18 years old with critical proximal LAD lesion who were undergoing elective PCI in cardiology unit, faculty of medicine, Al-Azhar University, Assiut from April 2021 to November 2021. Results: For E/A ratio, we found that the reduction in this ratio was significantly higher among those with preserved EF compared to others. The increase in IVRT and DT over 1 month period was statistically higher among those with preserved EF when compared with others. For E/A ratio, we found that the reduction in this ratio was significantly higher among those with preserved EF compared to others. Also, we found that average E/′E ratio was significantly reduced among those with preserved EF when compared to others.

P424 SMALL HEART AND SINGLE CORONARY ARTERY IN A YOUNG PATIENT WITH CHRONIC FATIGUE SYNDROME: A CASE REPORT

Abstract Introduction Chronic fatigue syndrome/Myalgic encephalomyelitis (CFS/ME) is a clinically defined condition reported mostly in adults, characterized by severe and disabling fatigue limiting normal daily activities for at least 6 months accompanied by multiple unexplained symptoms including self–reported impairments in concentration and short–term memory, sleep disturbances, and musculoskeletal pain. Although rarely considered to have cardiac dysfunction, CFS/ME patients frequently have reduced stroke volume with a significant inverse relation between cardiac output and post–exertional malaise severity. We describe a case of a young man affected by CFS/ME and small heart with incidental findings of anomalous origin of the left main coronary artery (LMCA). Case Presentation A 19–year–old Caucasian male presented to our clinic complaining weakness, lack of concentration and excessive daytime sleepiness. Medical history included CFS/ME, D hypovitaminosis, inflammatory bowel disease associated with pancreatic insufficiency. Physical examination including cardiovascular auscultation was unremarkable, with normal blood pressure and heart rate. Electrocardiogram showed sinus rhythm at 75 bpm without any repolarization abnormalities. Echocardiogram revealed reduced diameters of left ventricle (LV) (end–diastolic diameter 36 mm), normal aortic root dimensions and, in a five–chamber apical view, a binary structure that seemed to cross the aorta perpendicularly to its long axis. Cardiac magnetic resonance (CMR) found significantly reduced LV stroke volume (34 ml/m2; normal values 44–68 ml/m2) and end–diastolic volume (57 ml/m2; normal values 68–103 ml/m2) together with reduced end–diastolic wall mass (51 g/m2; normal values 59–93 g/m2). Also, right ventricle (RV) volumes were reduced: stroke volume (32 ml/m2; normal values 40–72 ml/m2), end–diastolic volume (62 ml/m2; normal values 68–114 ml/m2). In addition, the exam confirmed the anomalous origin of LMCA stemming from the proximal segment of right coronary artery and following a retro–aortic course. Conclusions Not sufficient consideration was given to cardiovascular involvement in patients with CFS/ME, although many of signs and symptoms are suggestive of cardiovascular dysfunction. This case highlights that CFS/ME together with small heart is a condition possible also in young people. More studies and reports could be necessary to better define the association with cardiac congenital anomalies and CFS/ME.

P157 THE UNFORESEEABLE LINK: A CASE OF CORONARY–PULMONARY ARTERY FISTULA BRIDGING THE RIGHT CORONARY AND FIRST SEPTAL BRANCH OF THE LEFT ANTERIOR DESCENDING ARTERY

Abstract Coronary–pulmonary artery fistulas are a rare clinical entity with a variety of potential clinical manifestations. Albeit rare, such anomalies may in some instances involve multiple coronary arteries and go unnoticed until old age producing little to no clinical manifestations. We hereby present the case of an 83–year–old man, heavy smoker, with a history of cor pulmonale due to severe chronic obstructive pulmonary disease (COPD) who was recently diagnosed with metastatic lung adenocarcinoma. Incidentally, one of the ECGs performed revealed negative T waves in the precordial leads in the absence of symptoms and with a negative troponin curve. Echocardiography was thus performed and revealed severe left ventricular systolic dysfunction (EF 31%) with infero–postero–lateral akinesia. The patient underwent CT coronary angiogram, which ruled out any significant coronary stenosis but revealed a most surprising finding. An ectatic arterial branch running anteriorly and draining into the pulmonary artery connected the the proximal segment of the right coronary artery to the first septal branch of the left anterior descending (LAD) artery. Unfortunately, the severe left ventricular failure contraindicated any chemotherapy and the patient was discharged with a plan to start palliative radiotherapy. Three months later, the patient returned to our Hospital due to worsening weakness, cachexia and one episode of pre–sincope. During this hospital stay, he developed atypical chest pain with a significant troponin curve. A HRCT and pulmonary angiogram was performed, which revealed neoplastic progression with bilateral lung involvement and bone metastases, as well as bilateral segmental pulmonary emboli. Echocardiography demonstrated new segmental areas of akinesia (apical septum and mid–apical anteroseptal segment) suggestive of focal ischemic damage. Given the documented pulmonary embolism and the anomalous connection between pulmonary artery and coronary circulation, this event may have been caused by paradoxical embolism travelling from pulmonary to coronary circulation (most likely affecting the LAD artery territory). Due to the patient’s frailty however, this hypothesis could not be confirmed by coronary angiography. Despite their relative rarity, coronary–pulmonary artery fistulas involving multiple coronary arteries can occur in the elderly population with no previous clinical manifestations and may give rise to apparently unfathomable clinical constellations.

770 Small heart and single coronary artery in a young patient with chronic fatigue syndrome: a case report

Abstract Aims Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a clinically defined condition reported mostly in adults, characterized by fatigue and unexplained aspecifical symptoms. Patients with CFS/ME frequently have reduced stroke volume with an inverse relation between cardiac output and post-exertional malaise severity. We describe a rare case of a young man affected by CFS/ME, small heart, and anomalous anatomy of left main coronary artery (LMCA). Methods and results A 19-year-old Caucasian male referred to our clinic complaining weakness, lack of concentration, and sleepiness. He suffered by CFS/ME, D hypovitaminosis, inflammatory bowel disease, and exocrine pancreas insufficiency. Blood tests revealed no pathological findings. Faecal exams documented intestinal dysbiosis and low pancreatic elastase. He was treated with oxygen-ozone rectal insufflations and probiotics. Physical examination was unremarkable. Electrocardiogram showed normal sinus rhythm. Echocardiogram revealed reduced diameters of the left ventricle (LV), normal aortic root dimensions and, in a five-chamber apical view, a binary structure that seemed to cross the aorta perpendicularly. Cardiac magnetic resonance (CMR) found reduced LV stroke volume (34 ml/m2) and end-diastolic volume (57 ml/m2) together with reduced end-diastolic wall mass (51 g/m2). Right ventricle volumes were reduced too. In addition, the exam confirmed the anomalous origin of LMCA stemming from the proximal segment of right coronary artery and following a retro-aortic course. Mechanism of CFS/ME remains unknown, although various factors have been implicated, including immune activation, chronic viral infection, and emotional disorders. A considerable number of patients affected by CFS has an anatomically small heart. Small heart syndrome, in fact, may contribute to the onset of CFS/ME. Previous studies hypothesized that clinical manifestations of CMS/ME were caused by reduced venous return, cardiac output, and heart mass, together with decreased arterial oxygen saturation. Single coronary artery is an uncommon congenital anatomic abnormality identified by a single coronary ostium giving rise to all arteries supplying the heart. Thus, we reported a rare case of a very young man affected by chronic fatigue syndrome and small heart, investigated not only with echocardiogram but also with CMR, not often used in this clinical setting. More, we found an anomalous origin of LMCA. From literature, it’s not reported any cases of a patient including these three rare conditions (CFS/ME, small heart, and single coronary artery). Conclusions This case highlights that CFS/ME together with small heart is a condition possible also in young people. More studies and reports could be necessary to better define the association between cardiac congenital anomalies and CFS/ME. 770 Figure

Abstract 13024: Excessive Slow Flow and Thick Boundary Layers Cause Non ST Segment Elevation in Patients With Patent Coronary Arteries

Introduction: Many patients arrived to emergency room with atypical chest pain, borderline ST segment elevation, troponin level significantly elevated however the coronary angiogram was normal. Why? Hypothesis: Based on damages by flow disturbances in pipes, our research is built on the hypothesis that flow abnormalities disrupt delivery of oxygenated blood to the myocardium. Our strategy is to use today’s practice of fluid mechanics to unlock the mechanism of non-ST Segment elevation myocardial infarction (non-NSTEMI) and patent coronary arteries. What coronary flow abnormalities were the culprit? Methods: Patients with non-STEMI were enrolled if the coronary arteries were patent. In our new dynamic angiographic protocol, contrast was injected until the index coronary artery was completely opacified. Once the manual injection stopped, the blood moved in, displacing the contrast. The movements and directions of the blood flow in “white” color on top of a “black contrast” background could be clearly analyzed. The main focuses were the types of flows and their duration, direction and length. Results: 12 patients with non-STEMI and patent coronary arteries were enrolled. 100% patients had severe slow flow with prolonged arterial phase (&gt;1.8secs) compared with historical control (0.72 secs) (p&lt;0.05). 83% patients had retention flow with thick stagnant boundary layers at the proximal and mid segment of right coronary artery. The retrograde flow was short (0.18secs). Two patients showed excessive contraction of left ventricle. 4 patients revealed history of intense emotional stress however no sign of adrenergic excess (elevated blood pressure, heart rate or extreme peripheral vasoconstriction). All patients recovered and remained asymptomatic after one year follow-up. Conclusions: In non-STEMI and patent coronary arteries, severe slow flow and prolonged retention of thick boundary layers were the culprits. Besides the ischemia caused by delayed delivery of new blood to myocardium, the prolonged retention of thick boundary layers could prevent the intima from absorbing new oxygenated blood and provoked local ischemia. These new discoveries open new management and preventive options for patients with non-STEMI and patent coronary arteries.

Coronary perivascular inflammation in type 2 diabetes mellitus patients: the missing piece in the puzzle of their increased cardiovascular risk?

Abstract Background Coronary atherosclerosis is a frequent complication of type 2 diabetes mellitus (DM2). Considering the contiguity with the vascular wall, perivascular adipose tissue (PVAT) could play a crucial role in the pathogenic microenvironment of atherosclerosis. The PVAT attenuation index (p-FAI) is a non-invasive marker that reveals the change in peri-coronary adipose tissue (PCAT). High values of p-FAI are associated with increased cardiovascular mortality and poor prognosis. Emerging as an indication, contributor to, and therapeutic target for atherosclerosis, PCAT warrants further investigation in DM2. Purpose We aimed to characterize the association of PCAT by p-FAI and DM2, and to compare coronary inflammation in DM2 versus non DM2 patients with coronary artery disease (CAD), and versus healthy controls. Methods 15 consecutive DM2 patients (9 male, age 63±10 years) without symptoms/signs of cardiovascular disease were included in the study and compared to 8 non DM2 patients with CAD and 13 healthy volunteers without cardiovascular diseases, matched for age and sex. All patients and controls underwent coronary computed tomography angiography (CCTA) for the evaluation of coronary arteries and p-FAI. All scans were performed using a 320-slice multidetector computed tomography (Toshiba Aquilion) and a prospective ECG-triggered sequential acquisition. p-FAI analysis was performed using a dedicated workstation (Aquarius iNtuition Edition version 4.4.13. P3; TeraRecon Inc., Foster City, CA, USA). The proximal 40-mm segment of the right coronary artery (RCA) was identified and the inner and the outer wall were automatically traced, excluding the 10 mm from the ostium. The adipose tissue localized within a radial distance from the outer wall equal to a medium diameter of the RCA was evaluated. Voxel histograms of CT attenuation were traced and included between −190 to −30 HU within the PCAT volume. p-FAI was calculated as the median CT attenuation value of PCAT of the proximal 40-mm segment of the RCA (Figure 1). Results CAD was present in 10 DM2 patients (5 males, aged 63.1±10.5 years); in 5 DM2 patients (4 males, aged 63±11 years) epicardial coronary arteries were normal. p-FAI was higher in DM2 patients than in healthy controls (p=0.004). The presence of CAD did not impact on p-FAI in DM2 patients, presenting a comparable value (p=0.37). p-FAI was higher in DM2 patients with CAD than in non DM2 patients with CAD (p=0.04). Moreover, p-FAI was higher in DM2 patients without CAD than in non DM2 patients with CAD (p=0.002, Figure 2). Finally, p-FAI was not different in non DM2 patients with CAD compared to healthy controls (p=0.65), suggesting the limited role of CAD in the progression of peri-coronary inflammation when compared to DM2. Conclusions Coronary inflammation evaluated by p-FAI measurement was higher in DM2 patients, also without CAD. Therefore, our results suggest that DM2 is a determinant of coronary inflammation stronger than CAD. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

INFLAMMATORY STATE AS A CAUSE OF STEMI IN A PATIENT PRESENTATION WITH DKA

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: One of the major complications of diabetes mellitus includes hypercoagulability due to platelet hyperactivity, coagulation activation, and hypofibrinolysis. Acute hyperglycemia is hypothesized to exacerbate the coagulation pathway by enhancing the activities of factor VII, VIII and tissue factor pathway inhibitor. The prothrombic state observed in diabetic ketoacidosis (DKA) is due to endothelial activation, augmented activity of platelets, and increased concentration of von Willebrand factor. In the case of inflammatory bowel disease (IBD), however, thrombotic events occur due to an increase in coagulation factors including factor V, VII, VIII, prothrombin, and the thrombin-antithrombin complex. Other studies have noted that the decrease in factor XIII in active Crohn's disease is related to consumption of factor XIII in forming microthrombis. We are presenting a unique case of a STEMI that was provoked by the presence of two hypercoagulable disorders, IBD and DKA. CASE PRESENTATION: The patient is a 41-year-old male with significant PMH of type I diabetes mellitus complicated by gastroparesis and multiple admissions for diabetic ketoacidosis, as well as Crohn's disease not on immunosuppressive therapy. The patient presented with a chief complaint of intractable nausea, vomiting and diffuse, non-radiating abdominal pain. On admission, he was tachycardic, tachypneic, and normotensive. His laboratory studies were consistent with DKA. Abdominal X-ray showed fluid distension in the stomach, similar to previous CT abdomen findings, coinciding with his significant history of gastroparesis. EKG revealed ST elevations in leads II, III, aVF and V3-V6. He underwent a cardiac catheterization, which revealed thrombus in the proximal segment of the right coronary artery with no obvious underlying coronary artery disease. He underwent mechanical thrombectomy only, with no stent deployed. The patient was discharged with goal-directed medical therapy and to continue dual-antiplatelet therapy for one year. DISCUSSION: DKA can cause various complications including hypercoagulability. There are proposed hypotheses for risk of developing thromboembolic disease in both DKA and IBD. The patient had a significant history of recurrent admissions due to DKA with non-specific EKG changes. The patient in this case had a history of Crohn's disease, and was not on any immunosuppressive medications. If the patient's comorbidities had been better controlled, it is possible that the patient would not have suffered this STEMI. CONCLUSIONS: The patient had two hypercoagulable disorders that could have led to formation of the intracoronary thrombus. This case demonstrates the importance of management of chronic diseases and their effects on other organ systems. REFERENCE #1: Hazan, Tal, et al. "Hypercoagulability in Crohn's Disease: a Complex Pathology: ... : Official Journal of the American College of Gastroenterology: ACG." LWW, Sept. 2008, journals.lww.com/ajg/fulltext/2008/09001/hypercoagulability_in_crohn_s_disease__a_complex.1104.aspx. REFERENCE #2: Giannotta, Martina, et al. "Thrombosis in Inflammatory Bowel Diseases: What's the Link?" Thrombosis Journal, BioMed Central, 2 Apr. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4393581/. REFERENCE #3: Lemkes, BA, et al. "Hyperglycemia: a Prothrombotic Factor?" Journal of Thrombosis and Haemostasis : JTH, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/20492456/. DISCLOSURES: No relevant relationships by Saad Chaudhry, source=Web Response No relevant relationships by Mary Dickow, source=Web Response No relevant relationships by Kristen Hughes, source=Web Response No relevant relationships by Zaid Kasmikha, source=Web Response No relevant relationships by Verisha Khanam, source=Web Response

Coronary artery dissection after exercise stress

The article represents data on the frequency and causes of coronary artery dissection. The types of dissections and approaches to their treatment are given. A case of dissection of the right coronary artery (type F) in a young man after signifi cant physical stress with the development of type 2 myocardial infarction is described. Percutaneous transluminal coronary angioplasty with stenting of the remaining dissection of the proximal segment of the right coronary artery made it possible to prevent the recurrence of the disease.

Comparison of Framingham risk score and atherogenic indices as a predictor of atherosclerosis in patients with myocardial bridge in left anterior descending artery

Background Myocardial bridge (MB) is generally considered as a benign condition, but it may trigger atherosclerosis, especially in the adjacent proximal coronary artery segment. In this study, we aimed to investigate whether the Framingham risk score (FRS) or atherogenic indices are risk factors for coronary atherosclerosis in patients with MB in the left anterior descending coronary artery (LAD). Methods We performed a retrospective study evaluating 155 patients who have MB in LAD. The patients were evaluated in two groups according to the presence of atherosclerosis (74 patients in atherosclerotic group vs. 81 patients in non-atherosclerotic group). Baseline characteristics, FRS and atherogenic indices were reviewed between groups. Significant independent risk factors for coronary atherosclerosis were investigated by logistic regression analysis. Results Patients in atherosclerotic group were significantly older (58.15 ± 10.04 vs. 50.22 ± 9.27 years, p < .001) and 74.3% of the patients were male. While the mean FRS in the atherosclerotic group was 21.20 ± 8.81, it was 12.79 ± 8.61 in the non-atherosclerotic group (p < .001). Among the atherogenic indices, only LDL-c/HDL-c ratio was significantly higher in the atherosclerotic group (3.49 ± 1.2 vs. 3.11 ± 0.98, p:.033). Multivariable analysis showed that age (OR: 1.08, 95% CI 1.03–1.13, p < .001) and FRS (OR: 1.06, 95% CI 1.01–1.11, p:.012) were independently associated with the presence of atherosclerotic lesion. Conclusions FRS is an easily applicable predictor in clinical practice that indicates the presence of coronary atherosclerosis in patients with MB in LAD.

Total occlusion of coronary artery without ST-segment elevation a case series of ‘de Winter’ electrocardiogram pattern

Background: A ‘STEMI equivalent’ electrocardiogram (ECG) pattern describes an acute thrombotic occlusion of a large coronary artery without ST-segment elevation. This pattern must be recognized and treated with emergent reperfusion therapy. De Winter syndrome is a special ECG pattern reflecting acute occlusion in the proximal segment of LAD (left anterior descending) coronary artery and a primary percutaneous coronary intervention (PCI) should be performed as early as possible.Case illustration: We present two patients admitted to the emergency department with symptoms of chest pain. Their ECGs revealed de-Winter T waves and then coronary angiography was performed. Total occlusion in the proximal segment of the LAD coronary artery was observed in both patients, and stents were implanted to the culprit lesion. Both ECG patients show an up-sloping ST-segment depression (STD, &gt;1 mm) starting from the J-point, with symmetrical, tall and significant T-waves in the precordial leads. This ECG pattern indicates a LAD coronary artery obstruction. The ‘de Winter’ ECG pattern is not mentioned in the ESC guidelines, but it is essential to recognize this rare ECG pattern as the STEMI equivalent, and it must be treated with prompt revascularization therapy.Conclusion: The ‘de Winter’ ECG pattern, as other ‘STEMI equivalent’, must be recognized promptly and treated as soon as possible with emergent reperfusion by percutaneous coronary intervention.

A case report of multisite arterial thrombosis in a patient with coronavirus disease 2019 (COVID-19).

BackgroundA systemic coagulation dysfunction has been associated with COVID-19. In this case report, we describe a COVID-19-positive patient with multisite arterial thrombosis, presenting with acute limb ischaemia and concomitant ST-elevation myocardial infarction and oligo-symptomatic lung disease.Case summaryAn 83-year-old lady with history of hypertension and chronic kidney disease presented to the Emergency Department with acute-onset left leg pain, pulselessness, and partial loss of motor function. Acute limb ischaemia was diagnosed. At the same time, a routine ECG showed ST-segment elevation, diagnostic for inferior myocardial infarction. On admission, a nasopharyngeal swab was performed to assess the presence of SARS-CoV-2, as per hospital protocol during the current COVID-19 pandemic. A total-body CT angiography was performed to investigate the cause of acute limb ischaemia and to rule out aortic dissection; the examination showed a total occlusion of the left common iliac artery and a non-obstructive thrombosis of a subsegmental pulmonary artery branch in the right basal lobe. Lung CT scan confirmed a typical pattern of interstitial COVID-19 pneumonia. Coronary angiography showed a thrombotic occlusion of the proximal segment of the right coronary artery. Percutaneous coronary intervention was performed, with manual thrombectomy, followed by deployment of two stents. The patient was subsequently transferred to the operating room, where a Fogarty thrombectomy was performed. The patient was then admitted to the COVID area of our hospital. Seven hours later, the swab returned positive for COVID-19.DiscussionCOVID-19 can have an atypical presentation with thrombosis at multiple sites.

Rheumatic valvular heart disease combined with woven coronary artery: a case report

BackgroundWoven coronary artery (WCA) is an extremely rare congenital anomaly in which a part of epicardial coronary artery is divided into thin channels, that twist along the axis of the coronary arteries and then merge again as the main coronary lumen. This anomaly is regarded as a benign condition because the blood flow is normal. Very few cases of WCA have been reported.Case presentationHerein we report a case of a 44-year-old man who was admitted to our hospital due to 20 years of repeated episodes of heart palpitations, 2 years of shortness of breath after activity, and the symptoms were aggravated for 1 month. He had history of inferior myocardial infarction and atrial fibrillation. Color Doppler echocardiography revealed rheumatic heart disease, severe mitral regurgitation, mild-moderate tricuspid regurgitation, moderate pulmonary hypertension. Coronary angiography revealed 60–85% diffuse stenosis in the middle of left anterior descending artery, 60–90% diffuse stenosis in the middle of left circumflex artery, 30–40% diffuse stenosis in the proximal segment of right coronary artery, and WCA anomaly in the middle, and distal segments of right coronary artery.ConclusionThe patient successfully underwent prosthetic valve replacement and left anterior descending coronary artery bypass grafting, and had a good recovery after surgery. Further studies are needed to fully understand the disease and determine appropriate treatment options.

Feasibility of Non-contrast-enhanced Coronary Magnetic Resonance Angiography at 3.0T

Objective To evaluate the feasibility of non-contrast-enhanced magnetic resonance angiography (NCE-MRA) on a 3.0T scanner. Methods Totally 36 volunteers and 24 patients with clinically suspected coronary artery disease underwent NCE-MRA. The quality of the NCE-MRA images was graded for each segment on a four-point scale. The subjects were divided into two groups according to image quality. The age,body mass index (BMI),heart rate,end-expiratory diaphragm displacement,and respiratory diaphragm motion amplitude were evaluated and compared. Results The average image quality score of every segment was above 2 points. The proximal and middle segments of left anterior descending artery had significantly higher quality scores than the distal segments (P=0.000) and the proximal segment of left circumflex coronary artery had significantly higher quality scores than the distal segments (P=0.000),the proximal segment of right coronary artery also had a significant higher quality score than its distal segment (P=0.001). The image quality was good in 38 subjects (64.4%). The heart rate [(66.35±9.39) beat/min vs. (75.32±11.67) beat/min] (P=0.002) and the body mass index [(24.72±3.33) kg/m 2 vs. (27.82±3.61) kg/m 2] (P=0.002) were significantly different between the good image quality group and the poor image quality group. The end-expiratory diaphragm displacement in good image quality group was (4.43±2.07)mm,which was significantly lower than that in poor image quality group [(9.26±7.62)mm](P=0.013). The respiratory diaphragm motion amplitude [(21.35±6.02) mm] in good image quality group was significantly lower than that in poor image quality group [(30.68±14.20)mm](P=0.012). Conclusion NCE-MRA on 3.0T is a feasible tool for visualization of the proximal and middle segments of coronary arteries,and the image quality can be optimized by controlling heart rate and respiration in the future.